FOAM, free open access medical education, is an online movement taking place across social media, blogs, and podcasts that is challenging traditional methods of medical education.1,2 Its acronym coined in 2012, FOAM represents more than just the content of the learning resources; it is considered to be an ethos, a dedication to the learning and teaching of medicine in a collaborative environment made easily accessible by online platforms.1 These new educational platforms are changing the way learners engage with educational resources and how research is translated into practice.3 Recent studies have demonstrated that 97.7 percent of American medical residents are spending at least one hour per week supplementing their traditional academic curricula with podcasts.4 This rapid expansion and increasing influence of FOAM in emergency medicine suggests a need for ethical analysis. Pros and cons of FOAM from an ethical perspective are outlined in Table 1. The ensuing discussion elaborates on these key issues emergency physicians should consider when utilizing or participating in FOAM.

Patient Confidentiality

Our responsibility to protect patient privacy and health care information takes on new complexity in the FOAM and social media environment. The risks, especially when discussing clinical case vignettes or sharing radiographic or electrocardiographic content, are well described.5 Attentive care to “de-identification” of publicly shared content requires not only removal of key patient details (eg, names, ages, and birth dates) but also more subtle identifiers such as unique conditions, events, locations, and time lines. When participating in FOAM, emergency physicians should follow the guidelines established in ACEP’s forthcoming policy on use of social media.

(click for larger image) Table 1: Pros and Cons of Characteristics of FOAM

Conflicts of Interest

The disclosure of FOAM authors’ conflicts of interest should follow the same standards recognized by traditional peer-reviewed journals, namely that all professional and financial conflicts be fully disclosed to readers.6 In FOAM, this expectation should apply not only to content authors but also commentators. A high-traffic website, social media page, or Twitter feed has significant potential value for advertising revenue. A complete ban on industry sponsorship or ad placement is not a tenable solution, as there can be substantial costs in the creation of high-quality FOAM content. Disclosing these conflicts is crucial. Transparent and reduced-bias funding sources for FOAM, such as grants, may mitigate but not reduce the risk posed by conflicts of interest.

Similar to the publication bias of journals, there may be selection bias for content that will be of interest to and shared by users. This constant pressure for innovative and engaging posts, particularly in concert with the limitations in peer review, may create content that misrepresents standard practices by emphasizing new techniques and studies. Furthermore, the lack of verification of the identity and credentials of commenters clouds the reliability of information and opens the door to covert industry infiltration, astroturfing, and other malicious intents. Social media platforms common to FOAM, as well as social media users in general, have proven to be extremely vulnerable to manipulation and dissemination of false information. There is an ethical imperative for the FOAM community to establish firm safeguards, aggressively self-regulate, and promote the skepticism that is the bedrock of scientific advancement.

There is an ethical imperative for the FOAM community to establish firm safeguards, aggressively self-regulate, and promote the skepticism that is the bedrock of scientific advancement.

Peer Review

Attempts have been made to implement formal peer review in FOAM. The blog Academic Life in Emergency Medicine (ALiEM) introduced an “expert peer review” process for providing feedback, edits, and commentary on published articles while still not delaying their release. Furthermore, there are emerging structured mechanisms to evaluate nontraditional educational sources (eg, ALiEM AIR Series and AIR Score, Medical Education Translational Resources: Impact and Quality [METRIQ], and Social Media Index).7–10

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2 Responses to “We Must Analyze and Clear Up the Ethical Issues in FOAM”

This is a great article on a timely topic. The free, worldwide access that effectively uses multimedia is a major selling point for me. I get some of the cons, but feel like #FOAMed users consume these resources as part of their continuing education and most #FOAMed resources focus on research rather than trying to avoid peer review for new ideas.

#FOAMed tools are a great adjunct and proper incorporation into education seems to be a focus of leading groups like SAEM’s Social Media Committee, ALiEM, and ACEP’s Council of EMed Residency Directors (CORD).

Many FOAMed resources have a strict conflict of interest policy that is similar to medical journals. Industry/pharma influence is far more pervasive in peer reviewed journals than in FOAMed. Example: https://emergencymedicinecases.com/conflict-interest-policy/.
The following issues are not unique to FOAMed but to many medical education resources:
1. Patient confidentiality issues are the same regardless of whether the resource is a peer reviewed article or FOAMed resource.
2. World wide access is true for texbooks, peer reviewed journal articles, FOAMed resources.
3. No Curriculum is true for texbooks, peer reviewed journal articles, FOAMed resources. Universities set curriculums based on all of the above.
4. Eminence vs evidence is true for any speaker at any medical conference and any opinion leader writing an editorial in a peer reviewed journal.